2024 年 144 巻 6 号 p. 691-695
In Japan, only few hospitals have pharmacists in their secondary emergency rooms to record medication history and provide drug information in real time. In this study, we investigated the benefits of pharmacist intervention in secondary emergency rooms by comparing the time taken by the pharmacists and non-pharmacists in the emergency room to record the medication history in the electronic medical record and the accuracy of its content. The study period was from September 1 to September 30, 2022, and included patients who were transported to our hospital for emergency care between 9:00 and 16:30. We compared the time taken between the patient’s arrival until the recording of their medication history and the accuracy of the record by the emergency room pharmacists and non-pharmacists (paramedics or medical clerks). The study included 58 patients whose medication histories were collected by pharmacists, and 11 patients whose histories were collected by non-pharmacists. For pharmacists, the median time to record medication history in the electronic medical record was 12 min, whereas for non-pharmacists, it was 19 min, which was significantly different (p=0.015). The pharmacists accurately recorded the medication history of 98.3% (57/58) of patients, whereas non-pharmacists accurately recorded it for only 54.5% (6/11) of patients, with a significant difference (p<0.01). We observed that in secondary emergency rooms, when pharmacists were responsible for recording the patients’ medication histories, it resulted in rapid and accurate sharing of medication history.
A wide variety of drugs are used in secondary emergency rooms, as those are visited by patients with different diseases. Therefore, intervention by pharmacists who are experts in medicine in the secondary emergency rooms is highly necessary. However, very few hospitals in Japan have pharmacists working in secondary emergency rooms to collect information, such as medication history, and to provide drug information in real time.
Since April 2021, pharmacists have been working in the secondary emergency room of Fukuoka Tokushukai Hospital from 8:30 to 17:00 on weekdays. A multidisciplinary team of physicians, nurses, paramedics, pharmacists, and medical clerks collected information and provided treatment to the patients brought to the emergency room. The patient information and assessments obtained from each individual professional were recorded in the electronic medical record and shared with all the professionals. Before pharmacists started working in the emergency room, details on the patients’ medication were mainly collected by the paramedics and medical clerks and recorded in the electronic medical records. However, as different pieces of information, such as the patient’s current medical history and family information, were collected simultaneously, recording in the electronic medical record was slow, and sharing of medication history took a long time. When the pharmacists assumed responsibility for this task, they collected the patient’s medication history and recorded it in the electronic medical records. This may have contributed to a reduction in the time required for sharing medication history, but the actual time-saving effect is not clear. In addition, the medication histories collected by the paramedics and medical clerks often lacked information on dosage and administration, which suggested that accurate information may not have been shared. As this may affect the physician’s diagnosis, it is important to record the information accurately, including not only the name of the medicine, but also its dosage and administration.
Over the years, different studies have reported improvements in the recording of the medication history in emergency departments when recorded by pharmacists; however, there have been no reports of pharmacists collecting medication history in secondary emergency rooms in Japan.1–3) Saito et al. reported that pharmacists took approximately 2 h to record information on medications brought by patients to the secondary emergency room.4) However, in our hospital, medication history is collected immediately after a patient is brought to the emergency room; therefore, it is possible to share this information in a shorter time period than that reported by Saito et al. In this study, we investigated the benefits of intervention by a pharmacist in secondary emergency rooms by comparing the time taken and accuracy in recording the medication history in the electronic medical record between pharmacists and non-pharmacists in charge of the emergency room.
One pharmacist worked in the secondary emergency room during the day shift on weekdays (8:30–17:00). The main duties of the pharmacist in charge of the emergency room included collecting information about medication history, adverse drug reactions, and allergies of emergency patients and recording it in the electronic medical record; refilling medications; adjusting the dosage of medications; suggesting additional medications; and responding to questions from other professionals. When pharmacists collect medication histories, their primary objective is to ascertain the details within these histories that will provide the physician with the necessary information for diagnosis. Furthermore, in instances where acute drug intoxication is suspected, the pharmacist checks the quantity of medication brought by the patient. Additionally, when necessary, medication adherence is assessed by interviewing patients and their family members. The medication history was collected by paramedics or medical clerks when the pharmacist was on a break, when the pharmacist was attending to other patients, and during the night when the pharmacist was not working. The medication history records are not standardized among all pharmacists and non-pharmacists. Approximately 3–4 paramedics and medical clerks work in the emergency room every day and are never absent.
2. Survey Period and Target PatientsThe study period was from September 1 to September 30, 2022, and included patients who were transported to our hospital for emergency care between 9:00 and 16:30. The inclusion criteria necessitated the immediate commencement of medication history collection upon the patient’s arrival from the emergency room. Consequently, exclusion criteria were applied to a broad spectrum of patients: those transferred from other hospitals, individuals requiring cardiopulmonary resuscitation upon emergency transport, patients who were not evaluated by a pharmacist or a non-pharmacist, cases lacking a medication history, those with an unknown medication history, and instances where the medication history was exclusively composed of prescriptions from our hospital. In addition, we excluded patients who were attended by a pharmacist, but brought to the emergency room during the pharmacist’s dispensing duties or during a break, which delayed the intervention. This information was examined retrospectively by extracting it from the electronic medical records.
3. Time Taken to Collect and Record the Medication HistoryWe compared the time taken by the pharmacists and non-pharmacists (paramedics and medical clerks) for recording the patients’ medication history in the electronic medical records starting from their arrival to the emergency room. Medication history was collected using the patient’s medication record book, prescription drug information sheet, medicine envelope, and medications brought by them, and verbal confirmation with them if any information was missing.
4. Accuracy of the Medication History and Number of Medications CollectedBased on the study by van den Bemt et al., we investigated four items for assessing the accuracy of medication history information: “no dosage,” “no single dose,” “no specification,” and “incorrect drug name.”5) For missing drugs, we examined the number of drugs for which information could be collected as a surrogate indicator, as the information used to collect the medication history could not be verified. The “no dosage” and “no single dose” categories were determined for only oral medications.
5. Statistical AnalysisFisher’s exact test was used to compare proportions between the two groups, and Mann–Whitney U test was used to compare medians between the two groups, with a risk rate of less than 5% being considered as significant difference. EZR software (version 1.61) was used for all statistical analysis.6)
6. EthicsThe Ethics Committee of Fukuoka Tokushukai Hospital declared that the present study did not require any approval. Nonetheless, all data were handled in accordance with best practices.
The study included 58 patients whose medication histories were collected by pharmacists, and 11 patients whose histories were collected by non-pharmacists (Fig. 1). Among these, 29 of the 58 patients (50.0%) assessed by pharmacists and seven of the 11 patients (63.6%) evaluated by non-pharmacists did not necessitate hospitalization following emergency transport. The most common source of information about medication history was the medication record book (81.0%) (Table 1). The median time to record medication history in the electronic medical records was 12 min for the pharmacists and 19 min for the non-pharmacists, resulting in a significant difference (p=0.015). The pharmacists accurately recorded the medication history of 98.3% (57/58) of the patients, whereas non-pharmacists accurately recorded it for only 54.5% (6/11) of the patients, resulting in a significant difference (p<0.01). Accuracy errors included two cases of no dosage, three cases of no single dose, two cases of no specification, and two cases of incorrect drug names by non-pharmacists. The median number of medications recorded from the medication history information for pharmacists and non-pharmacists was 8 and 6, respectively, slightly higher for pharmacists, but not significantly different (p=0.10) (Table 2).
| Medical professional who collected the patient’s medication history | Pharmacist (n=58) | Non-pharmacist (n=11) | p-Value |
|---|---|---|---|
| Median age [IQR] | 76 [67–84] years | 71 [61–84] years | 0.83a) |
| Male/female | 29/29 | 4/7 | 0.52b) |
| Hospitalized from ER/returned home from ER | 29/29 | 4/7 | 0.52b) |
| Sources of medication history | |||
| Medication record book | 47 (81.0%) | 10 (90.9%) | 0.88b) |
| Prescription drug information sheet | 4 (6.9%) | 1 (9.1%) | |
| Medication record book+Medicine envelope+Medications brought by the patient | 1 (1.7%) | 0 | |
| Medicine envelope+Medications brought by the patient | 5 (8.6%) | 0 | |
| Verbal confirmation with the patient | 1 (1.7%) | 0 | |
a)Mann–Whitney U test. b)Fisher’s exact test. IQR: Interquartile range; ER: emergency room.
| Pharmacist (n=58) | Non-pharmacist (n=11) | p-Value | |
|---|---|---|---|
| Time [IQR] | 12 [8–19] min | 19 [16–22] min | 0.015a) |
| Accurate medication history | 57 (98.3%) | 6 (54.5%) | <0.01b) |
| Inaccurate medication history | 1 (1.7%) | 5 (45.5%) | |
| No dosage | 1 (1.7%) | 2 (18.2%) | 0.064b) |
| No single dose | 1 (1.7%) | 3 (27.3%) | 0.012b) |
| No specification | 0 | 2 (18.2%) | 0.023b) |
| Incorrect drug name | 0 | 2 (18.2%) | 0.023b) |
| Number of medications recorded in the medication history | 8 [4–12] | 6 [3–7] | 0.10a) |
a)Mann–Whitney U test. b)Fisher’s exact test. IQR: Interquartile range. The time taken includes the time starting from when the patient was brought into the emergency room until the medication history was recorded in the electronic medical record.
In this study, we found that pharmacists could collect the medication history of patients in secondary emergency rooms and record it in electronic medical records more quickly and accurately. This result promotes pharmacists’ participation in the emergency room by showing that pharmacists should be made responsible for collecting medication history in secondary emergency rooms.
After arrival of an emergency case, information about the patient is transmitted from the ambulance crew and the patient’s family to the paramedics or medical clerks in the emergency room. It takes a long time to collect and record the patient information in the electronic medical record, as it included not only medication history but also current medical history and family history. Pharmacists are in charge of only collecting information related to medications, such as medication history and adverse drug reaction history. Thus, the time at which medication history could be recorded in electronic medical records by pharmacists is shorter than that by non-pharmacists. This time is comparable to that reported elsewhere.7) Saito et al. reported that it took approximately 2 h to record information about the medications brought by patients, which is different from the results of the present study.4) Saito et al. intervened after the patient was admitted to the hospital and checked the number of remaining medications and listed alternative medicines; therefore, it is possible that it took longer to complete recording the medication history. In contrast, when our emergency room pharmacists oversaw the emergency room, they intervened as soon as the patient arrived and were able to record their medication history at an earlier time. This information was digitized into electronic medical records and communicated verbally when necessary. Due to the inability to quantify the extent of verbal exchanges and the time dedicated thereto in this study, the duration of entering medication history into electronic medical records served as a proxy measure of efficiency. Notably, the pharmacist played a pivotal role in several critical instances: identifying adrenal insufficiency prompted by non-adherence to steroid medication, detecting serotonin syndrome due to a pharmacodynamic interaction between selective serotonin reuptake inhibitors and dextromethorphan, and recognizing a history of immune checkpoint inhibitors therapy, which expedited the diagnosis of immune-related Adverse Events. A pharmacist’s prompt intervention and efficient collection of necessary data in a time-sensitive, emergency room setting would be extremely helpful in treating the patient. The effective collection of a patient’s medication history is necessary to ensure that they receive proper medical care, as it is a crucial component of the treatment plan. Therefore, patient safety can be increased by having pharmacists quickly gather medication histories in our emergency room.
When non-pharmacists recorded the medication history, there was concern regarding the accuracy of the information related to the medication, as there were several cases with no dosage or no specification in the information recorded by non-pharmacists. Beyond the duration of this study, numerous instances were identified wherein medication histories inaccurately recorded in the electronic medical records by non-pharmacists led to incorrect prescriptions for the continuation of pre-admission medications after emergency hospitalization. Conversely, no dosage and no single dose were found in only one patient when the medication history was recorded by pharmacists, and this was due to the fact that the information was taken verbally from the patient, and thus, it could not be recorded accurately. As the strength of a medication’s effect may vary depending on its administration time and dosage, it is necessary to gather pertinent information and record it correctly. In a large percentage of cases in this study, the information about medication history was taken from the medication record book. Therefore, it was assumed that the dosage and specifications of the drugs were noted in the book. Throughout the study period, the method for recording medication history in electronic medical records was not standardized, potentially resulting in variability in the recording methods among individuals, which could have influenced the results. Consequently, the education of non-pharmacists and the standardization of medication history documentation are crucial to ensuring precise and uniform recording of medication history in electronic medical records. Although paramedics and medical clerks can collect information about the name of drugs and their dosages, it is unlikely that they would be able to understand the efficacy, correct dosage, and administration of the drug. Pharmacists, conversely, understand the efficacy, proper dosage, and administration of various drugs and can provide information to physicians based on the pharmacological considerations from the collected medication history. Hospitalization due to adverse drug reactions accounts for 3.3–3.5% of all emergency room admissions; therefore, collecting medication histories and providing relevant information to the physicians are critical for the diagnoses of adverse drug reactions.8–10) Consequently, pharmacists checking the medication histories in secondary emergency rooms can provide advice from a pharmacological perspective to physicians at an earlier stage and in real time and may make significant contribution to patient outcomes in emergency rooms.
A limitation of this study is that we could not confirm the accuracy of the medication history information recorded in the electronic medical records, as the collected medication history cannot be verified retrospectively. However, the medication record book is a major source of information about the medication history, and we believe that there is only a low possibility of error while transcribing this information. In addition, for patients whose medication history could not be obtained directly from them, the medication history may be incomplete. In addition, although non-pharmacists were defined as paramedics and medical clerks in this study, the results cannot be generalized, since, in other hospitals, medication histories may be collected by nurses, physicians, and other professionals. The results may have been influenced by the staffing balance between the pharmacists and non-pharmacists in the emergency room, fluidity of the work performance, number of years of work experience, and number of patients transported to the emergency room. However, pharmacists were superior in terms of time taken to share the information and accuracy of medication history. In Japan, where pharmacists have not yet been assigned to secondary emergency rooms, we believe that our results provide useful information regarding the development of pharmacy services in secondary emergency rooms. We hope that in future, further studies will be conducted to confirm the benefits of pharmacist’s intervention in secondary emergency rooms in Japan.
The results of this study showed that when pharmacists were responsible for recording the patients’ medication histories in secondary emergency rooms, it enabled rapid and accurate sharing of the medication history.
We are grateful to the pharmacists at Fukuoka Tokushukai Hospital, who contributed to this study.
The authors declare no conflict of interest.
